NSW Coroner Michael Barnes this morning delivered the findings from the inquest into the deaths arising from the Lindt Cafe siege in Martin Place on December 15, 2014.

He described gunman Man Haron Monis as a “vicious maniac (who) oscillated between feigning regard for (the hostages’) welfare and threatening to blow them apart”.

“The terror they endured could fairly be described as torture,” the coroner said.

Mr Barnes told a packed the courtroom at Sydney’s John Maddison Tower that a psychiatrist called in by police gave erroneous assessments of the situation inside the cafe and issued ambiguous advice, which contributed to police underestimating the threat Monis posed.

The coroner said the siege “would have challenged any police force in the world”.

Lindt Cafe manager Tori Johnson, 34, was one of 18 people held hostage for 17 hours before he was shot at point blank range by gunman Man Haron Monis, 50, at 2.13am on December 16.

Police stormed the cafe 59 seconds later and killed Monis.

Mother and barrister Katrina Dawson, 38, was killed by a fragment of a police bullet in the crossfire.

Throughout the inquest — which started six weeks after the siege — police were heavily criticised for not storming the stronghold before hostages were killed.

“The deaths and injuries that occurred as a result of the siege were not the fault of police,” Mr Barnes said.

“All of the blame for those rests with (gunman) Man Haron Monis.

“He created the intensely dangerous situation, he maliciously executed Tori Johnson, he barricaded himself into a corner of the cafe and his actions forced police to enter the cafe in circumstances where the risk of hostages being wounded or killed was very high.”

But Mr Barnes said “mistakes can’t be papered over if outcomes and public safety are to be improved”.

Some of the most controversial evidence tendered during the inquest related to the police response with the probe hearing vital information wasn’t passed on to commanders quickly enough and resources were lacking.

In his findings, the coroner said emergency action “should have been initiated” by tactical police when Monis fired shots at fleeing hostages at 2.03am on December 16. “The 10 minutes that lapsed without decisive action by police was too long,” Mr Barnes said.

Police commanders previously told the inquest they held off sending tactical officers into the cafe earlier because of concerns the gunman had a bomb in his backpack.

He said the first shot “made it clear there was little to no chance of resolving the siege” and that hostages inside were still at “extreme risk of harm”.

“Tori Johnson was executed in the meantime before the decision to enter the cafe was made,” Mr Barnes said.

After the findings were delivered, NSW Police Commissioner Mick Fuller told reporters that “in hindsight, NSW Police should have gone in earlier”.

“I accept the criticisms,” he said.

“As first commander I believed there was a bomb.

“It’s too easy (in hindsight) to dismiss the bomb.”

Among those in court for the inquest findings were Ms Dawson’s parents Sandy and Jane Dawson and brother Angus Dawson, and Mr Johnson’s partner Thomas Zinn, mother Rosie Connellan and father Ken Johnson.

They sat through the long-running inquest — which heard from dozens witnesses over 23 weeks of hearings — for most of the hearings.

Then NSW Police Commissioner Andrew Scipione, Deputy Commissioner Catherine Burn and Assistant Commissioner Jeff Loy had previously been grilled on the stand about allegedly interfering inappropriately with operational matters during the siege. But today Mr Barnes cleared them of any wrongdoing.

Mr Barnes also rejected the view of some commentators that the Australian Defence Force should have assumed responsibility for the siege. “With all due respect to those of that view, it is simplistic and unrealistic,” he said.

He said there are legal obstacles to the ADF carrying out armed domestic action and the Lindt Cafe siege was not one of the situations where that could take place.

THE CORONER’S RECOMMENDATIONS

The coroner’s 600-page report contained 45 recommendations including the NSW Police force conduct a review of training for negotiators.

Mr Barnes also made recommendations for improvement of the assessment of politically-motivated violence and inter-agency information sharing and co-operation.

Inquest into the deaths arising from the Lindt Café Siege: Findings and Recommendations — (State Coroner of New South Wales)

Excerpts:

Treatment History (Page 70)

160. In the second half of 2005, a general practitioner referred Monis to Dr. Daniel Murray, psychiatrist at St JOhn of God Health Care in Burwood, Sydney. Monis said he was being harassed, discriminated against and “psychologically tortured” by Customs Service officers when he passed through Sydney airport. Monis told Dr Murray he had been forced to leave Iran and that his family were political prisoners there.

162. It seems likely that Monis’ visits to Dr Murray were part of a deliberate effort to prove that he was suffering harm as a result of his treatment by the Australian Customs Service , with which he was in dispute.

163. Between May 2009 and Sept 2011, Monis saw 10 different GPs and mental health clinicians. In most cases he complained of psychosomatic symptoms, including dizziness, weakness in his leg, shaking and pain all over his body. Test and examinations revealed no physical ailment. One doctor made a diagnosis of delusional disorder, but that was never followed up.

164. From May, 2010, Monis saw Dr Kristin Barrett, a psychiatrist attached to the Canturbury Community Mental Health team. He had seven consultations with her over 16 months. At his first few visits, Dr Barrett thought Monis showed signs of paranoia. He wore a cap and sunglasses and avoided eye contact. He was guarded, and Dr Barrett found it difficult to elicit information from him.

165. At the time, Dr Barrett diagnosed chronic schizophrenia, although she noted that Monis was usually high-functioning (meaning he could work and interact soially). She prescribed risperidone, an anto-psychotic drug used to treat schizophrenia or bipolar disorder, and later sertraline, and antidepressant. Over the ensuing months, Monis’ paranoid delusions seemed to become less intense, and Dr Barrett concluded that the drug treatment was helping him.

166. In Sept 2011, Monis told Dr Barrett that he had not taken any prescription medication for three months…

168. After Monis was charged in early 2014 with being accessory to is ex-wife’s murder, he was held briefly on remand and was assessed by staff of Justice Health and the Department of Corrective Services. He said he had never had a mental illness.